A few seasons ago I went to see my namesake performing on the New York stage. I can see why he was so cut up about it.
CHAPTER VI
ALL THIS GOSSIPING, HOWEVER, HAS KEPT ME away from the story of the Bureau itself, which is, after all, the main point. Once I was in that job, I stayed in it till I retired. This is a one-track story.
Fortunately for me, my checkered past of playing factotum for the Department of Health had long since cured me of any apprehension about striking out in a new job. I did not appeal to myself as a pioneer in a new field, however—there was nothing so rhetorical about it as that. It was just that here was something that needed doing and should be approached in the most practical way. If someone had come up to us and said, with a light in his eye: “Ladies and gentlemen, you are doing a great humanitarian task that has never been done before!” we would only have said: “Not really?” and gone on figuring out whether or not that vacant delicatessen store on Avenue A would do for a new baby health station. We did not have time to dramatize ourselves.
Nevertheless, little as we realized it, we had a tremendous technical and strategical advantage in the fact that we were pioneering. There were no precedents to hamper us, no body of established knowledge to prevent us from seeing needs and remedies clearly and directly. Our one guiding principle was to start babies healthy and keep them so and, if that objective led us into far fields, all the way from the young east-side bride’s diet to the habits of certain herds of cows in Jersey, we could go right along without wondering if our procedure were orthodox. As I look back, I can even be glad that we started with relatively little money and that our budget-increases, which eventually made us the most expensive bureau in the Department, came with tantalizing slowness. With neither time nor money to waste, we had to cut clean to the bone and eliminate waste motion as religiously as if it had been the eighth deadly sin.
Even in a little detail like records we had to cut our coat according to our cloth and were all the better for it. When the Bureau first started, it was endowed with a set of records specially worked out for it by the Bureau of Municipal Research. This was a fine institution but it knew very little about children and had a fetish about record keeping. The cards they gave us for school inspection required inspector and clerk to fill out the same form with the same information eleven times. I had visions of my whole meager staff with heads bowed down over clerical work and no time for anything else. The nurses’ cards were just as bad. Night after night I labored over drawing up a set of forms to simplify matters and yet get all useful information into the indicated hands—and then one happy day I threw out the old lot and put my new forms into operation. It was like cleaning sand out of the gear-box of a car. To this day around seventy-five percent of the school-inspection and baby-health-station systems in the United States use duplicates of that system I perspired and agonized over because my newborn bureau was slowly suffocating under heaps and heaps of waste-paper. I did not want to pay out good money for pencils and carbon paper. But it was not the taxpayer I was thinking of—it was the babies who needed medicine and milk.
I was by no means the logical person for the job of constructing an organization for saving babies. It should have been in the hands of a person with all the theory and practice of governmental administration right at his fingers’ ends. And I was just a harmless young woman from a small town who had been forced by circumstances into becoming a doctor for lack of any career that attracted her more. On the face of it I am still a doctor. In fact, when I took my degree as Doctor of Public Health in 1917, I became a doctor for the second time. But, largely by accident, I was forced into becoming an executive and having less and less to do with the practice of medicine. It is queer how, after the necessary jostling and shaking, you usually end up in the right spot. I was probably cut out to manage things, although it took me a long time to find it out. Whether I had started in a biscuit factory or a profession or a suburban kitchen, I would probably have ended up behind a desk somewhere making the telephone and a staff of assistants jump around in the interests of some widespread scheme or other. Perhaps that was why I so welcomed this venture into uncharted seas.
They were uncharted. No doubt it was just the right moment for some such experiment and someone else would have been starting it if we had not, but at that time the world was shockingly innocent of the kind of organization we found ourselves building. Only a few sporadic efforts of private organizations to solve certain aspects of the problem, such as the milk stations in Cleveland, Boston, Philadelphia, where modified milk for infant feeding was dispensed by private philanthropy to a handful of mothers, and school medical inspection of the most elementary type in a few cities. I have already given some idea of the inadequacy and slovenliness of school medical inspection as we found it. There was a badly administered child-labor law in New York State. That was all. Nothing coordinated, no governmental agency, federal, state, or municipal, which had been delegated any responsibility for children. A barbarous situation, when you look back on it from the vantage point of 1939. Eventually we took over the superintendence of the child’s well-being from before birth till he turned the corner into adulthood.
When we started our campaign, we had a little knowledge developed out of our trial beginnings. The battle against infection in the worst schools was already well under way under a fine corps of nurses. The astonishing diminution in the baby death rate resulting from our attempt to educate slum mothers indicated a fertile field for further development. So we looked about for another point of attack, and decided that the midwives needed attention. Something had to be done about these women if far too many of our prospective charges were not going to be brought into the world maimed and blinded. And all that anybody knew about the midwife situation was that it was a crying scandal.
Although the midwife is as old as mankind, she was something of an anomaly in an American community, where the public had long been educated into the conviction that an M.D. and a hospital are the best combination for bringing children safely into the world. In New York thirty years ago, however, the huge recently landed immigrant population had kept the midwife tradition thoroughly alive. These Italian, Hungarian, Polish, Armenian, Greek, Slovak and other mothers had been accustomed to midwives in their native villages and wanted them here in the new country. They might not have been so badly off in experienced hands at home in the Balkans, but the New York midwife was likely to be a very clumsy practitioner indeed who had got into the profession as an amateur and stayed in it to make a living. She was usually densely ignorant and therefore filthy, superstitious, hidebound, everything a good midwife should not be. Most of them eked out their scanty incomes from legitimate lyings-in by performing illegal operations under conditions that made you wonder how any of their patients survived. It was pretty grim business for these poor mothers who not only shrank from the idea of a man-doctor but couldn’t afford him or a woman-doctor either.
Our first step was to install an efficient licensing system. The city had regulations requiring licenses, but enforcement was lax to the point of non-existence and proved nothing. No one knew how many midwives were practising or where or how. We went to the state legislature and secured new and stringent licensing laws for midwives in New York City, which were to be administered by the Department of Health. With the city in the picture, the midwives all had to come in and apply for licenses—a tremendous round-up—almost four thousand of them, I remember. They were all women of middle age or better, gabbling strange tongues, and dumb and frightened in the face of the fact that for the first time the law was checking up on them. They were too frightened to object to anything we wanted to do. Nevertheless, in order to gain their confidence and assure them we were not trying to run them out of business, we made the requirements easy. All you needed was a certificate from a doctor stating that you had been in attendance at twenty or more cases of childbirth under his supervision—something extremely easy to get. Everyone got a license, from the wri
nkled old veteran who had had long experience in a Dalmatian hill town and probably knew as much about practical obstetrics as any doctor in New York, down to the shifty, filthy abortion-monger from Mott Street.
The medical profession, particularly the obstetricians, made a great deal of trouble for us at this point. Their idea was that the best thing would be to stamp out midwifery altogether instead of compromising with it. The doctors were never able to understand the sort of people we had to deal with. If deprived of midwives, these women would rather have amateur assistance from the janitor’s wife or the woman across the hall than submit to this outlandish American custom of having in a male doctor for a confinement. Their daughters, the second generation of mothers, were a different matter, and learned to insist upon employing doctors as stubbornly as any American girl. We licensed every midwife for the purpose of finding her address; after that it was a simple matter to deal with the ones who were unfit.
When they were accustomed to strict licensing, we began to require that future midwives earn the right to practice. Later, in 1911, a special midwives’ school of obstetrics was started at Bellevue Hospital, and from then on we refused licenses to new applicants who were not graduates of either this school or a European school of equal standing. The Bellevue course, under city control, was for six months and free—but comprehensive and efficient, as it should have been. Its graduates knew more about delivering babies than three-quarters of the recently graduated internes entering on medical practice in this country that year. Then, when we started arresting and convicting some of the abortionists, most of the others moved to New Jersey or elsewhere, which weeded out the worst specimens and considerably reduced the number of midwives in practice. Before we began our work, midwives had been delivering about half the babies born in New York. Nowadays there are only about seven hundred of them in practice and they deliver less than a tenth of the annual births. A few years ago the Bellevue school was closed for lack of students.
I would not regard cutting down the number of trained midwives as necessarily a good thing under all circumstances. If I had a daughter who was going to have a baby, I would rather see her in the hands of one of those competent Scandinavian midwives who, in their own countries, work in squads under supervision of an obstetrician, than in the hands of the average general practitioner. A well-trained midwife deserves all possible respect as a practical specialist. It is by no means unlikely that the fact that the United States’ maternal death rate is higher than that of any European country is predominantly due to American distrust of midwives. For, in the majority of instances, a first-class midwife has probably handled more maternity cases than any doctor except a veteran obstetrician. The obstetrician is, of course, the best possible person to bring a child into the world. But, since the economic factor rules him out in many cases, the midwife, who is not allowed to go beyond natural deliveries, often gives both mother and child a better chance than is possible with the over-use of anaesthesia and the mechanically assisted deliveries which some doctors use unskilfully in order to spare the patient pain.
I remember getting into a hot discussion with the New York Academy of Medicine on that point. I had published some figures which made it pretty clear that the maternal mortality rate from infection at the time of childbirth among mothers delivered in hospitals by doctors was far higher than among mothers delivered at home by midwives. Naturally that annoyed the Academy and I must admit that on the face of it, it made little sense. I had a very bad hour indeed sitting at an Academy meeting as the target of all kinds of pointed remarks—they did not exactly call me a liar, but they skirted around it much too close for comfort. Then, to prove their point, they started an investigation of their own. That was my innings. In preparing my figures I had been absurdly careful to make them as unfavorable as possible to my point of view. If a midwife had so much as walked into the room where a prospective mother was in bed, her death would be placed to the discredit of the midwife, even if it had occurred while the case was under the doctor’s care. Since the Academy did not go into these details quite so carefully, their figures, when they were finally compiled, were even more favorable to the midwives than mine.
There is little doubt in my mind, that, until American students receive far more thorough training in obstetrics than they do now, the properly trained and properly supervised midwife is a better practical obstetrician than a great many general practitioners have ever had a chance to be. It is not the doctor’s fault. He is lucky if, upon entering practice, he has so much as been on hand during a few deliveries, let alone handled one himself. In other words, he may be equipped with only a rough, second-hand knowledge of the delicate technique involved. He does not particularly want obstetrical cases when he starts practice, except as a way of getting patients, because they are an immense amount of bother for relatively low fees. So, unless he decides to specialize in obstetrics, which is not the most glamorous or best-paying branch of medicine, he never gets that long course of baby after baby which eventually gives the midwife an uncanny skill in making deliveries normal everyday affairs.
But remember I am recommending only the well trained and well supervised midwife. It is still a disgrace that, in view of her possibilities as a practitioner for all but prosperous people, so little has been done about her in this country even now. There are whole regions of the United States, particularly in the South, where the midwife’s status is still as irregular, hit-or-miss and consequently lethal as it was in New York when we started cleaning up the situation. Following our lead in these districts would be a long and dirty job for anybody who tried it, but thoroughly worth while if you admit that a baby has a right to be born whole.
The Crede technique—a drop of one percent silver nitrate in each eye immediately after birth to prevent gonorrheal infection—was required in all cases. When we started bringing the midwives under genuine regulation, there were hundreds and hundreds of children in New York blind asylums because no midwife had ever heard of Crede and probably would not have bothered with the drops if she had. We made every midwife telephone us at once if there was any sign of irritation in the eyes at all, and an inspector was sent immediately to make the diagnosis and to see that the baby had the appropriate care. A midwife lost her license if she did not use the drops in every case. But the silver nitrate solution they used did not work out satisfactorily. It was usually in a bottle in the midwife’s kit, generally dirty and always evaporating up to a dangerous strength. So, among our other concerns, we had to invent a fool-proof, sanitary, convenient way of packing the solution. With the assistance of the Schieffelin laboratories we finally worked out a neat little package—two beeswax capsules, each containing enough solution for one eye, packed in a little box with sterile needles for puncturing the capsules. One puncture, one squeeze into the eye and there you were. That little capsule is all over the world now. And, due to its religious use, cases of congenital blindness have practically disappeared in New York City.
That is a fair sample of the way we were always having to use our mother-wit and invent something which had not existed before because no one had taken into account the practical circumstances under which underprivileged children are born and brought up. When we started educating slum mothers in the necessity of ventilation, for instance, we ran into the unconquerable European prejudice on the subject of drafts and night air. An Italian or Roumanian mother knew, as certainly as she knew the sun was going to rise next morning, that to expose a room to outside air after dark was tantamount to suicide and she was pretty apprehensive about an open window between September and June in any case. Neither persuasion nor scolding succeeded; the open window was unattainable. So we had to think of some way of getting ventilation with closed windows. The answer proved to be a plain wooden board, its length the width of the window. Mrs. Galeazzi would consent to open her window if she could immediately fill the gap at the bottom with a comfortably impermeable board, and its appearance reconciled her to the fact that a certain
amount of air was coming in between the sashes. A reasonable compromise, all things considered—and absolutely the best we could do until Mrs. Galeazzi’s daughter grew up and became sufficiently Americanized to look on open windows with approval.
I even found myself turning couturière and designing an entirely new system of baby clothes in order to reduce the slum mother’s resistance to giving up her traditions of swaddling-bands and overdressing. An abdominal band, a shirt, a diaper, an underpetticoat and a dress was our old formula—involving three different occasions when the arms of a squirming baby had to be put through armholes. So I worked out the obvious but previously unthought-of system of making baby-clothes all open down the front and laying them out like a fireman’s clothes before the baby appeared on the scene—dress wide open, petticoat on that with the armholes on top of the dress’s sleeves, shirt on that, diaper down below all spread out, abdominal band on that—then you laid the baby on his back in the middle of it, put his arms through shirt, petticoat and dress in two motions, did up the band and diaper, buttoned everything, and there you were. The dress was made big in the shoulders and not as long as the three-foot baby-dress of those days, so that by the time the child was grown to the short dress stage, he had just about grown up to the same clothes. The whole idea worked so well in our affairs that the McCall Pattern Company heard of it and offered to try it on the world of prospective mothers in general. They sold sets of patterns for it and, at a royalty of a cent apiece, it made a very neat addition to a rising young woman’s income. The Metropolitan Life Insurance Company ordered two hundred thousand of these patterns for distribution to their policy holders.
We had more rule-of-thumb practicality when the sickeningly high death rate in one of our largest foundling hospitals brought me up there to see what was wrong. I have never seen such a perplexing mystery as that place presented. The foundling babies were dying at the rate of about fifty percent—in other words, every other baby. Yet the death rate in the whole city, even before our work was well started, was only twelve percent in children below one year. And you could not possibly call it the hospital’s fault. By that time I had acquired a flair for hospital inspection and there was apparently absolutely nothing wrong. Intelligent, well-trained nurses carrying out the last technique to the letter, absolute spotlessness and sanitation, approved feeding; nothing was wrong except that the babies were dying like flies, poor little wretches.
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